Medical/Surgical Unit Survey

MedSurg Unit Patient Survey

McCurtain Memorial Hospital
McCurtain Memorial Hospital would like to invite you to participate in this survey. We want to hear from you how your stay was at our Hospital. Please share your experience with us below. This information will be sent to the Executive Leadership at MMH to recognize our staff for great care and to address any concerns that you may have had during your stay.
Patient's Name (You do not have to provide your name)

First NameLast Name
Your Email:
example@example.com
Admission Date*

MonthDayYear
Date
Room #:*

Doctor's Name:
In your own words, share with us how you felt your care was with this Doctor:*
On a scale of 1 Star to 5 Stars, with 5 being the best, how would you rate this Doctor?*

Who was your nurse? If you had more than one, please list them here:*
How well did your nurse(s) take care of you? Were your need met? Was your nurse compassionate and attentive to your needs? Provide all of the detail you would like:*
On a scale of 1 Star to 5 Stars, with 5 being the best, would you rate your nursing team during your stay?*

Did you receive Physical Therapy or Occupational Therapy while in the Hospital?
If you answered "Yes" to receiving therapy, please tell us about that experience and the Therapist that you worked with during your stay:

Please tell us any additional information that you feel we should know. Also, please share any recognition that you would like to provide. If you want to recognize any staff member, please do so here. We sincerely appreciate your feedback and participation in this survey.
How likely are you to recommend McCurtain Memorial Hospital?*
Should be Empty:

	Yes	No
Were you seen each day by a doctor?
Do you feel your medical needs were met?
Was your room clean when you arrived?
Was your room cleaned each day?
Was the food good?
Did you get enough portions to eat?
Was the Dietary staff friendly?
Was you provided an opportunity to clean/wqsh your hands before meals?
Was your dirty tray picked up timely?
Was meals delivered timely?
Did you find that you were hungry between meals?
Did you receive a bath or assistant doing so if you needed it?
Was the bathroom cleaned daily?
Ws your bathroom stocked with towels and toiletries each day?

MedSurg Unit Patient Survey